Health Policy Research Paper

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Abstract

Health policy refers to the decisions, plans, and actions that are undertaken by organizations to promote health. In practice, health policy is a dynamic process involving setting health-related goals, designing systems and programs to meet those goals, implementing these systems and programs, and monitoring their outcomes. The array of decisions and actions that fall under the umbrella of health policy is vast, and the reach of these decisions can be profoundly influential. These decisions nearly always affect the health and well-being of groups of people, impose limits on individual rights, or require individual cooperation, so that many of the principles of bioethics are at play when these decisions are made and when they are carried out.

Introduction

Health policies affect the lives of every individual, every community, and every nation. Leaders in a position to set and carry out health policies ought to consider the ethical ramifications of their decisions and actions so that these policies are as effective and fair as possible. The history, definition, and goals of health policy are briefly described here. The application of ethical theory is then considered and some of the challenges faced by health policy decision makers are reviewed.

The History Of Health Policy

The history of health policy began far before the term “health policy” was coined. When human communities first began to care about and promote the health of their residents, they were executing, albeit not explicitly, health policy. As Dorothy Porter describes, in Health, Civilization, and the State, concern for health has been articulated and addressed throughout human history (Porter 1999). As views about the causes of illness have evolved, strategies for ensuring health have followed suit. In ancient civilizations, the concept of health was tied to the notions of morality. In medieval Europe, concerns regarding pestilence and public order predominated. During the Enlightenment, development and interest in the social sciences led to a focus on addressing factors that contribute to the health of populations. Along with the importance of the prevailing understanding of health and the causes of disease, shifting political influence played an important role in the efforts to promote health. As power shifted from ancient city-states to church authorities, monarchies, industrial powers, and national governments, responsibilities for assuring the health of the public have correspondingly shifted.

Definition

Health policy is closely aligned with the disciplines of medicine and public health, which aim to improve health through individually based and/or population-based interventions. The World Health Organization defines health policy as the “decisions, plans, and actions that are undertaken to achieve specific healthcare goals within a society. An explicit health policy can achieve several things: it defines a vision for the future which in turn helps to establish targets and points of reference for the short and medium term. It outlines priorities and the expected roles of different groups; and it builds consensus and informs people” (WHO 2014a).

Arguably, the term “health policy” has an even broader focus than the achievement of healthcare goals since healthcare alone will not suffice to achieve health. One might thus extend the definition of health policy to refer to “the decisions, plans, and actions that are undertaken to promote health.” In practice, health policy is a dynamic process involving setting health-related goals, designing systems and programs to meet those goals, implementing these systems and programs, and monitoring their outcomes.

Policy is translated into practice in many forms. Thus, operational policies may be reflected in the rules, regulations, guidelines, and administrative norms that governments or nongovernmental entities use to translate laws and policies into programs and services.

The Goals Of Health Policy

The predominant aim of health policy ought to be to promote population health. While this may seem straightforward, many questions with ethical implications underlie this goal. The foremost question concerns how health ought to be defined. Health may be defined narrowly as the state of being free of disease and injury, or it may be defined more broadly. The World Health Organization has articulated a broad definition of health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO 1946). A key question that undergirds this articulation of the goal of heath policy relates to how uniform the definition of health should be across nations that vary in their economic strength and development. Daniel Callahan has argued that societies that have greater resources and have longer life expectancies should have different goals than countries that have yet to reach such levels of achievement (Callahan 2002).

Once the goals of health policy are specified, subsequent policy questions arise regarding how they will be achieved and who is obliged to participate in achieving these goals. How will the achievement of selected goals be financed? To what extent will the achievement of goals be enforced? Given the complexity of modern societies and the task of promoting population health, innumerable organizational entities in both the public and private sector contribute to the overall achievement of a society’s overall health-related goals. These entities will have health-related missions that are much narrower in scope than the health-related goals of society as a whole, and hence the policy aims of these entities will be narrower. A hospital serving a particular community has the mission of promoting the health of that community. A state government within a country with a federal structure has a commitment to the health of the residents of that state.

Application Of Ethical Theory To Health Policy

The array of decisions and actions that fall under the umbrella of health policy is vast, and the reach of these decisions can be profoundly influential. These decisions nearly always affect the health and wellbeing of groups of people, impose limits on individual rights, or require individual cooperation, so that many of the principles of bioethics are at play when these decisions are made and when they are carried out. Policies undertaken by national governments or international organizations may have consequences for millions of lives. To the extent that health policies are global in scope, they ought to be based on common morality – the set of norms shared by all persons committed to morality. Yet it is more often the case that ethical guidance of health policy will rely on the ethical principles that have been articulated for medical practice, medical research, and subsequently public health. The principles of justice, autonomy, and beneficence clearly pertain to health policy as follows.

Justice

Theories of justice are accounts that offer defensible norms for deciding what is due to persons. Standards of distributive justice are involved whenever benefits, rights, and responsibilities are being distributed among people. Thus, distributive justice is central to policies that specify the funding and delivery of healthcare and to policies that dictate any social arrangements or programs that promote health.

The construction of a unified theory of justice has been extremely difficult. All theories of justice share a minimal requirement that equals must be treated equally, yet this principle of formal equality does not identify the particular respects in which equals ought to be treated equally or criteria for determining whether individuals are equal. Among the material principles of distributive justice that have been proposed, the principle that each person should receive treatment according to a fundamental need (a need that must be met to avoid harm) has been considered by many bioethicists to be the most germane. The rationale as articulated by Norman Daniels is that health is instrumental to equal opportunity; hence, healthcare and access to the resources that determine health are considered special needs. Abstract principles of justice offer only approximate guidance so that further deliberation is needed when setting particular policies (Daniels 2008).

Autonomy

An ethical analysis of health policy must consider how to respect the autonomous choices of persons in the course of efforts to promote and protect the health of populations and communities. As state authorities carry out functions to improve health, they are likely to pass laws and carry out policing functions that undermine the freedom of individuals to act and as they wish. Thus, a pivotal ethical dilemma that recurs in health policy decisions is the need to balance respect for individual freedom and liberty with the responsibility of governments to provide their citizens with some degree of protection in relation to health (Nuffield Council on Bioethics 2007).

Beneficence

The moral principle of beneficence imposes a positive obligation to act to benefit others. These obligations include the protection of the rights of others, prevention of harm, assistance to persons with disabilities, and rescue of persons in danger. As such, beneficence underlies the primary goal of healthcare and public health policies.

Rights

Theories of rights are also central to the ethical analysis of health policies. Rights are claims that impose duties or responsibilities on their duty-bearers. They focus on freedom, protection, status, or benefit for the right-holders. Human rights are norms that help to protect all people everywhere from severe political, legal, and social abuses. The ethical analysis of human rights addresses questions about the existence, content, universality, justification, and legal status of human rights. The main sources of the contemporary conception of human rights are the Universal Declaration of Human Rights and the human rights documents and treaties that followed in international organizations such as the United Nations, the Council of Europe, the Organization of American States, and the African Union (Nickel 2014).

Most germane to the ethics of health policy is the question that governments must consider regarding whether to guarantee a right to healthcare through more or less universal health insurance and/or health services. To the extent that health is determined by socioeconomic factors, economic and social rights are equally pertinent to health policy. These rights guarantee that every person be afforded conditions under which they are able to meet their basic needs. Economic and social rights include rights to education; sufficient food to guarantee freedom from hunger; the right to safe, secure, and affordable housing; social security, the means to procure basic needs and services; and the right to dignified, safe work that provides fair wages. Economic and social rights are protected under a wide range of international and regional instruments including declarations and covenants. Human rights declarations represent a commitment by signatory countries to meet stated human rights standards. Covenants, also known as treaties or conventions, are international law agreements entered into by governments. Once covenants or treaties are ratified, they become part of domestic law.

Challenges Faced In Health Policy And Their Ethical Ramifications

Governance Issues

Like other public policy, health policy inherently introduces ethical tensions between the interests of individuals and the welfare of society as a whole. Ethical frameworks justifying health policies are based on the principles of preventing of harm, improving social welfare, the efficiencies of collective action, or ensuring fairness (Faden and Shebaya 2010). However, in pluralistic societies, the goals of health policy to improve health must be balanced with the respect for individual autonomy in decision-making, raising ethical and political questions about the role of the government in protecting citizens from harm, promoting welfare, and ensuring a fair distribution of resources.

Health Policy And Public Health

The actions governments can take to directly promote health and well-being are wide-ranging. The Nuffield Council on Bioethics has categorized the kinds of governmental actions to promote public health on an intervention ladder based on the intrusiveness of the action; more intrusive actions require higher levels of justification to counterbalance the infringement on an individual’s autonomy (Nuffield Council on Bioethics 2007). The harm principle – the justification of interfering with the liberty of an individual is to prevent harm to others – is often seen as the most compelling and least controversial reason to justify interventions (Faden and Shebaya 2010). For example, highly intrusive interventions such as the compulsory isolation of patients with contagious infectious diseases are justifiable on the basis that they prevent others from being infected (Nuffield Council on Bioethics 2007).

More contentious is the role of governments when acting paternalistically and intervening not to prevent harm to others but to promote an individual’s welfare. Generally in liberal democracies, it is assumed that individuals are able to make decisions that will best serve their interests. For example, an individual choosing between a vanilla and chocolate cookie is more likely to pick the cookie that he or she prefers than a third party. However, healthcare decisions are often complex and it is not unreasonable to believe that individuals are not always able to make fully informed decisions. Therefore, minimally intrusive interventions that help individuals make informed decisions, such as nutritional food labeling, are often accepted with minimal controversy. However, actions such as legal limits on drinking age, smoking, or the use of helmets while driving a motorcycle are often more contentious on the grounds that they infringe on the rights of individuals to make autonomous choices.

Changing Behaviors And Compelling Actions

Public health initiatives that compel behavior must answer the question of whether it is acceptable to restrict an individual’s autonomy in order to further other goals. In recent years several ethicists have outlined frameworks for analyzing the ethical issues in public health (ten Have et al. 2010). Such frameworks provide concrete instruments that are aimed at assisting professionals in deliberating about the ethical aspects of programs and policy in order to support the day-to-day decision-making about their implementation (Dawson 2009). Childress et al. (2002) suggested that the general moral considerations to bear in mind in evaluating public health practices are (1) producing benefits; (2) avoiding, preventing, and removing harms; (3) producing the maximal balance of benefits over harms and other costs (often called utility); (4) distributing benefits and burdens fairly (distributive justice) and ensuring public participation, including the participation of affected parties (procedural justice); (5) respecting autonomous choices and actions, including liberty of action; (6) protecting privacy and confidentiality; (7) keeping promises and commitments; (8) disclosing information as well as speaking honestly and truthfully (often grouped under transparency); and (9) building and maintaining trust.

Thus, as public health officials consider programs to promote vaccination, smoking cessation, reduced substance abuse, weight reduction, safe sexual practices, and other healthful behaviors, these questions can help frame policies that are minimally invasive and maximally effective.

Organizational Aspects Of Governance

Of course, governance issues related to health policy go beyond the ethics of public health interventions. Governments play important roles in funding and setting priorities in healthcare, education of healthcare providers, and biomedical research. In addition, many governments play very active roles in the delivery of healthcare. Regardless of the issue at hand, the procedural aspects of how policies are made can have significant impact on the content, scope, and implementation of these policies. There are many models of how to conduct fair and effective decision-making (e.g., deliberative democracy).

Beyond the deliberative issues surrounding the process for making health policies, there are also practical concerns for governing. First, when there is multilevel governance within a country, at what level should health policy be made: national, state/provincial, or local? Certainly, health policies that should be uniform across the entire country, like the basic regulations surrounding the conduct of research, drug safety, and efficacy approval, or the negotiation of multinational compacts must occur at the national level. Others, such as the financing of local hospitals, distribution of healthcare products such as condoms, or imposition of taxes on cigarettes and alcohol, can be accomplished through either national or local programs. Health policy made at the national level often comes with more resources and allows for uniformity in rules and procedures. On the other hand, local control may result in health policies that are more responsive to the health needs of populations that may vary in ethnicity, culture, language, resources, geography, and political affiliations. Ultimately, however, the constitutional structure and normal division of powers within a country are likely to have a strong influence regarding the level at which health policy is made.

Another major structural concern related to governance arises from the multinational aspects of health policy, ranging from the impact of bilateral or multilateral agreements between nations and the role of nongovernmental organizations (NGOs). Compacts made between nations will ostensibly be mutually advantageous but may involve a country making trade-offs between interests. Whereas agreements between countries of relatively equal political and economic standing are likely to result in the fair distribution of benefits, more concerning are compacts made between countries of unequal standing. For example, free trade agreements are often aimed at reducing tariffs on goods traded between countries, which can yield an economic boom for low-income countries. However, these agreements often also include clauses strengthening intellectual property rights in low-income countries, constraining the ability of low-income countries to provide low-cost generic medicines.

Low-income countries that rely on donor support for a substantial portion of their healthcare budget have a further reduced ability to autonomously set health priorities; foreign aid may come with conditions that certain healthcare expenditures or other structural policy changes be made. Since the 1970s, direct aid has been less frequent and donations have been increasingly channeled to NGOs on the view that state services are plagued by inefficiency, corruption, and poor quality (Pfeiffer et al. 2008). However, the prominent role of NGOs can unintentionally weaken public healthcare infrastructure, acting as a brain drain of healthcare workers from the public sector to NGOs, fragmenting healthcare services, and lacking sustainability (Pfeiffer et al. 2008). Certainly, it becomes incumbent on donors to ensure that they engage in a collaborative partnership with the host country to improve population health; aid should be distributed in a manner that respects the needs of the host population and strengthens healthcare infrastructure.

The Role Of Priority Setting

Policymakers must decide how to allocate scarce resources in a way that best promotes the interests of the population. Thus, economic evaluation and priority setting play an important role in these kinds of decisions. Morris et al. (2007) classify the reasons why economic evaluation is used in healthcare decision-making as:

• To maximize the benefits from healthcare spending
• To overcome regional variations in access
• To contain costs and manage demand
• To provide bargaining power with suppliers of healthcare products

The ethical arguments underlying priority setting harken back to debates about which theory of distributive justice is most defensible, as noted earlier. Aside from these theoretical debates, several ethical considerations arise in the course of setting priorities as briefly discussed here.

Assessing The Burden Of Disease

It is not possible to prioritize interventions to improve health in the absence of systematic information about the distribution of disease and the burden it imposes on populations. To gather such information, the World Bank and the World Health Organization launched the Global Burden of Disease Study in 1991 and have revised and repeated this study in 1999–2002, 2004, and 2010 (Murray and Lopez 2013). A number of ethically contentious issues have surrounded this effort to measure the global burden of disease. Is the loss of a year of life equally valuable regardless of the age at which it is lost? Is the use of assessments of disability-adjusted life years (DALYs) as measured by pairwise comparisons of various health conditions done by healthy individuals a justifiable approach to valuing life years?

Guaranteeing Universal Health Coverage

The goal of universal health coverage is to ensure that all people obtain the health services they need without suffering financial hardship. As endorsed by the WHO, several elements are required: a strong, efficient, well-run health system; a system for financing health services; access to essential medicines and technologies; and a sufficient capacity of well-trained, motivated health workers (WHO 2014b). While this is a widely endorsed goal, Temkin (2014) has argued that pressure from the WHO and well-resourced countries to achieve it in countries that face extreme resource limits when there are many competing socioeconomic needs to be fulfilled to guarantee health is not necessarily advisable.

The Value Of Prevention Versus Treatment

It is generally much less expensive to prevent an individual from experiencing an illness or an accident than it is to treat it. Yet because prevention must be delivered to the entire population at risk while treatment needs to be delivered to the few who incur the illness, some argue that prevention is not as cost-effective as one might initially expect. To resolve this debate, careful cost-effectiveness analyses ought to be conducted. Aside from this concern, one should be aware that to prioritize preventive strategies over treatment might entail giving inadequate support to individuals who face substantial suffering when they do become sick.

Intergenerational Justice

As health policy leaders make decisions, an important ethical consideration regards the extent to which they should take into consideration the rights of past and future generations. With regard to past generations, for example, do leaders of countries that colonized in the past have an obligation to address current disparities out of a duty to repair past injustices? An argument in favor of such duty is that currently living people can stand under surviving duties to deceased victims owing to the wrongs committed against them (by others) in the past (Meyer 2010). With regard to future generations, do they need to consider the consequences of public policies they make today on the circumstances and opportunities that others will have to live with in the future? Do they need to avoid exhausting health funds today to allow for the funding of healthcare for others who will rely on a fiscally viable public insurance scheme in the future? Based on an understanding of the ethical significance of viewing ourselves as members of a transgenerational polity and community, present generations may well have duties of justice to future people (Meyer 2010).

Prioritizing Preparation For Ordinary Versus Catastrophic Events

Farsighted public health leaders recognize that they must plan ahead for catastrophic emergencies in order to respond to them adequately. Yet the outlay of resources for such preparedness for such unpredictable events poses an opportunity cost. They often reduce expenditures for routine health needs and thus may undermine the well-being of the most vulnerable segments of the population who are routinely the most underserved. Public health leaders must therefore assess the probability of and expected harm from such catastrophic events and weigh against the current unmet ordinary needs.

Financing Healthcare

Financing healthcare has two major facets: (1) financing of treatments and (2) payment of providers for their services. When creating mechanisms to fund healthcare systems, policymakers must take into consideration the principles of efficiency and equity.

Healthcare can be funded through a myriad of ways, such as general tax revenue, social health insurance (compulsory), private health insurance (voluntary), community-based financing, and/or out of pocket by the patient. Each of these financing mechanisms has limitations; thus, when crafting specific national programs, policymakers must develop holistic financing approaches specific to the needs, capabilities, and values of individual countries. Two general frameworks of healthcare financing predominate and will be described here: self-pay and resource pooling (e.g., insurance or taxes).

In the self-pay and user fee models, patients are directly responsible for paying either the entirety (self-pay) or a portion (user fee) of the costs for healthcare services at the point of service. The benefit of this model is that, when patients are well-informed, they will use resources in an efficient manner by evaluating trade-offs in risks, benefits, and cost (e.g., choosing the less expensive treatment for two equally effective drugs). However, these models are problematic due to the complex nature of medicine and unpredictability of illness. Patients often have imperfect knowledge on the risks and benefits of treatments, do not have much choice in providers, and have limited ability to negotiate the costs of treatment (e.g., emergency care). In addition, by placing the burden of funding on the patient, these models can be highly inequitable by limiting access to treatments to only those that can afford them and requiring sicker individuals to pay more.

The unpredictable nature of illness and the severe limitations of out-of-pocket financing, self-pay in particular, have generally led societies to pool resources in order to finance healthcare. These initiatives may be through private means (e.g., private health insurance) or public means (e.g., social health insurance, general tax revenue). The benefits of pooling resources, either through premiums or taxes, are twofold: healthcare funds are allocated in a predictable fashion and the burden of financing is spread across the population. Large health payers are often able to reduce healthcare expenditures by taking advantage of economies of scale through lower administrative overhead and greater bargaining power with healthcare providers. These funding systems are usually low cost at the point of care in order to promote the accessibility of healthcare services, regardless of a patient’s ability to pay. However, this setup also creates a moral hazard – an incentive to overuse healthcare resources without consideration of the costs or value of care. As a result, other means are used to ensure that resources are used wisely. Usually, these healthcare systems set policies that restrict the coverage of low-value care, for example, through drug formularies or reimbursement formulas, and rely on clinicians to serves as the gatekeepers of medical services.

A substantial portion of healthcare expenditures go toward the payment of clinicians for medical services. Furthermore, clinicians play a central role in the healthcare system, and policymakers must be aware of the role financial incentives play in modifying clinician behavior and influence healthcare delivery. Four major payment schemes are commonly used to compensate clinicians: fee for service, salary, capitation, and pay for performance. Each scheme provides incentives that, at times, can be at odds with the clinician’s professional responsibilities to their patients. A fee-for-service reimbursement scheme pays clinicians based on the services provided which can incentivize them to provide a higher volume of services, potentially resulting in an overutilization of healthcare resources. While payment of a salary can reduce incentives to base clinical decisions on treatment costs or reimbursements, providers on a salary may lack incentives to see many patients and thus have a reduced productivity of labor. Clinicians compensated under capitation, usually primary care providers, are paid a fixed sum per patient enrolled in their practice. While this system is meant to incentivize clinicians to think about the long-term health of patients and to use healthcare wisely, it also places clinicians in a position of substantial financial risk for taking on sicker patients, thereby limiting access to clinicians for sicker patients (e.g., adverse selection). Lastly, pay for performance compensates clinicians that meet certain quality standards, in theory aligning a clinician’s financial interests with patient’s well-being. However, such compensation schemes can be difficult to implement, and depending on how these schemes are structured, clinicians may also be incentivized to avoid treating sicker patients. Because of various drawbacks of each of these payment schemes, a combination of compensation schemes is often used.

Healthcare Workforce Issues

A well-trained healthcare workforce is paramount for any functioning healthcare system. Healthcare professionals, such as doctors, nurses, and pharmacists, represent a workforce requiring specialized tertiary education and clinical training; it can be difficult to train a healthcare workforce that is responsive to the health needs of a population. Market-based approaches are often insufficient or inapplicable as governments are often heavily involved in financing, regulating, and providing healthcare. As a result, governments often must play an active role in promoting an adequate healthcare workforce through financing medical education, providing clinical training opportunities, and providing sufficient compensation for medical professionals.

Despite these efforts, there is a global shortage of healthcare workers – the WHO estimates that as of 2006 there was a shortage of 4.3 million doctors, midwives, nurses, and support workers worldwide (WHO 2006). Lowand middle-income countries, in particular, face critical shortages in healthcare providers and significant challenges in training and retaining healthcare professionals. For example, in high-income countries, there are 2.5–4.0 physicians per 1,000 population, whereas in many sub-Saharan African countries, there are only 0.02–0.75 physicians per 1,000 population (the physicians to population ratio is a popular measure of the strength of a country’s healthcare workforce) (WHO 2013).

In part, this disparity is due to the limited resources available to fund the tremendous investment necessary to educate individuals through a tertiary education in medicine. However, a substantial contributing factor is “brain drain” resulting from healthcare professionals migrating to high-income countries. The WHO has estimated that 25 % of doctors and 5 % of nurses trained in Africa work in wealthy Organization for Economic Cooperation and Development (OECD) countries; in addition, 25 % of practicing doctors and 10 % of practicing nurses in the UK, USA, Canada, and Australia were trained in other countries (WHO 2006). This drain from low-income countries to high-income countries represents a huge cost to low-income countries that have invested significant resources to educate and train these healthcare professionals; many high-income countries rely on this supply of labor to adequately staff their own healthcare systems. Policymakers in high-income and low-income countries must work together to stem this contributor of global inequity.

International Dimensions Of Health Policy

The Importance Of An International Perspective: The Interdependence Of Health

While socioeconomic factors in a community or national context have powerful effects on population health, international factors that lie beyond local control also play an important role in determining health in any community or nation. Such international factors are wide-ranging. Diseases spread without regard to national boundaries particularly as global trade and international travel expand. Environmental factors such as air quality and climate change are similarly not merely the result of policies at the national level but rather are the cumulative result of energy policies and practices worldwide. The capability of nations to respond to illness is also not entirely domestically controlled. The level of expertise that can be mustered to respond to illness is heavily dependent upon the prevailing medical knowledge, medical technology, and medical practice guidelines that have accrued through the efforts of medical scientist and practitioners around the globe. Aside from medical expertise, many other factors including economic outlook that may be determined by trade agreements and international monetary policy influence the economic prosperity of a country and hence the fiscal ability of a country to support healthcare and public health policy. Similarly, international climate agreements may influence environmental conditions with profound impact on population health. Thus, international relations among nations affect the health status of one another’s residents.

To the extent that the actions of each country contribute to overall conditions such as climate, all nations face a collective action problem. This is often described as a “tragedy of the commons,” where an individual party has a self-interested reason to make a decision that results in a worse outcome for all compared to a case where all parties had organized to act collectively.

International Aid

Given the variation in the level of resources that communities in resource-rich and resource-poor countries have at their disposal, discussion of distributive justice raises the question of redistribution of resources through various means. To what extent should resources be redistributed among richer and poorer countries or among richer and poorer individuals within a country? Moral philosophers disagree strongly about whether redistribution is required. As Christian Barry clarifies, critics of redistributive policies often claim that while individuals may have positive ethical duties to aid poor or unwell persons, it is morally impermissible to compel them to do so through state-administered tax and transfer or other means, unless universal consent for these policies can be secured (Barry 2014). Egalitarians, on the other hand, have often argued that redistribution through compulsory taxation and other coercively imposed measures is required to meet basic material needs or to promote other valuable social goals and provide a legitimate though perhaps not morally costless means of doing so. These arguments regarding redistribution are germane to global health policy. According to a World Bank report, for example, in 2006, donors gave total development assistance to health, including aid from private organizations, amounting to US $16.7 billion (World Bank 2008).

Focusing On Health Policy Versus The Health Impact Of All Public Policies

The health of any population in any particular community is heavily determined by socioeconomic factors along with the level of performance of the local healthcare delivery system and local public health department. The social determinants of health are the circumstances in which people are born, grow up, live, work, and age that influence the vulnerability to disease or injury. For example, early childhood development, stress, and the availability of healthy food can have a profound impact on the quality of a person’s life, and these social factors of health are thought to be a strong contributor to health inequities. As health experts become aware of the social determinants, health policy experts must increasingly consider the health impact of policies in other public policy sectors. Toward this end, effort has been dedicated to performing health impact assessments of policies. To fully realize the benefits of such assessments, government agencies need to reduce policy silos and develop policies jointly.

Is Health Policy Sufficiently Informed By Evidence?

Unlike medical research, it is extremely difficult to design randomized trials of health policies, and once evidence is acquired, the translation of evidence into practice is a long and uncertain process subject to political and financial pressures. Although organizations like MIT’s Abdul Latif Jameel Poverty Action Lab (J-PAL) do conduct randomized trials of health policies, this is by no means a standard practice. Thus, many health policies, including laws, regulations, and judicial decrees as well as agency guidelines and budget priorities, are not based on solid evidence.

For example, Hartsfield et al. identified 107 model public health laws, covering 16 topics (Hartsfield et al. 2007). The most common model laws were for tobacco control, injury prevention, and school health; the least commonly covered topics included hearing, heart disease prevention, public health infrastructure, and rabies control. In only 6.5 % of the model laws did the sponsors provide details showing that the law was based on scientific information (e.g., research-based guidelines) (Hartsfield et al. 2007). Given the impact that public health policies have on people’s lives, it has been argued that health policy researchers have an obligation to facilitate evidence collection and policymakers ought to implement an evidence-based policy process; to develop policies that are most likely to be effective; and to document outcomes to improve, expand, or terminate policy (Brownson et al. 2009).

When an expert is in the position to make policy decision, the strength of the evidence that might be required to justify such a policy may vary. If a policy under consideration is expected to reduce a hazardous risk, the level of evidence required to institute it might be lower than if the risk is less hazardous; if a policy under consideration is expected to substantially undermine individual freedom or pose a great financial burden, the level of evidence required to institute the policy ought to be higher than otherwise.

In light of the paucity of systematic studies of health policies, comparative studies across countries offer an opportunity for learning about health policies that might not have been considered in their own country. In being open to such insights, policymakers can gain an alternative perspective and learn about policy solutions that might not have been considered acceptable in their country and in so doing on their own society that may be constructive.

Conclusion

Ethical reflection is central to setting and carrying out sound health policy. Ethical analysis can serve to identify the goals that health policy aims to achieve and can serve to guide the practice of health policy. Since health policy decisions are nearly always made in a context of constrained resources, policymakers inevitably must face trade-offs and must think explicitly about setting priorities. Thus, they must become skilled at explicitly and fairly distributing limited resources among the population they serve. While solid evidence has often been lacking, researchers are increasingly studying the consequences of health policies; hence, policymakers should make evidence-based decisions whenever possible. To the extent that health is determined by many factors that lie outside of the “healthcare sector,” leaders who set policy should think broadly across policy sectors. They should be cognizant of the health impact of many of the decisions that take place in society and, when possible, advocate for health promoting public policy in general.

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